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Recent studies indicate that participation in exercise-related games can improve executive function, attention processing, and visuospatial skills.
The aim of this study was to investigate whether exercise via exergaming (EXG) can improve executive function in patients with metabolic syndrome (MetS).
A total of 22 MetS patients were recruited and randomly assigned to an EXG group or a treadmill exercise (TE) group. The reaction time (RT) and electrophysiological signals from the frontal (Fz), central (Cz), and parietal (Pz) cortices were collected during a Stroop task after 12 weeks of exercise.
During the Stroop congruence (facilitation) judgment task, both the EXG and TE groups showed significantly faster RT after 12 weeks of exercise training. For N200 amplitude, the EXG group demonstrated significantly increased electrophysiological signals from the Fz and Cz cortices. These changes were significantly larger in the EXG group than in the TE group. Separately, for the P300 amplitude, the EXG groups presented significantly increased electrophysiological signals from the Fz, Cz, and Pz cortices, whereas the TE group showed significantly increased electrophysiological signals from the Cz and Pz cortices only. During the Stroop incongruence (interference) judgment task, both the EXG and TE groups showed significantly faster RT. For P300 amplitude, the EXG group had significantly increased electrophysiological signals from the Fz and Cz cortices only, whereas the TE group had significantly increased electrophysiological signals from the Fz, Cz, and Pz cortices.
EXG improves executive function in patients with MetS as much as normal aerobic exercise does. In particular, a unique benefit of EXG beyond increased aerobic capacity is the improved selective attention among cognitive functions. Thus, EXG could be recommended to someone who needs to improve their brain responses of concentration and judgment as well as physical fitness.
ClinicalTrials.gov NCT04015583; https://clinicaltrials.gov/ct2/show/NCT04015583
In recent years, the relationship between cognitive function and metabolic syndrome (MetS) has been widely studied [
Research on cognitive neuroscience employs Stroop tasks to measure selective attention capacity and skills as well as process speed ability to elucidate the nature of executive functions [
It is well-known that aerobic exercise training provides various beneficial clinical outcomes in metabolic disease patients [
Recently, exergaming (EXG, a combination of
Although many previous studies have reported improvements in cognitive function following EXG, it is not clear whether this benefit is due to an exercise effect or video game effect. In addition, all of these studies measured RT instead of ERP using EEG, which limits investigators seeking to illuminate brain activities. Considering that EEG can measure electrical activities in various cortex areas in the brain, it is necessary to investigate ERP using EEG to evaluate executive function. Therefore, we examined the benefits of EXG in comparison with normal exercise and investigated executive function by measuring RT as well as N200 and P300 in 3 cortex areas via Stroop tasks applied in patients with MetS.
A total of 22 MetS male and female patients aged between 50 and 80 years participated in this study. MetS was defined according to the modified National Cholesterol Education Program Adult Treatment Panel III definition for South Asians. Briefly, individuals with 3 or more of the following criteria were defined as having MetS: central obesity (waist circumference ≥90 cm for men or ≥85 cm for women); fasting plasma glucose ≥100 mg/dL or current treatment for diabetes mellitus; systolic blood pressure ≥130 mmHg, diastolic blood pressure ≥85 mmHg, or current treatment for hypertension; serum triglyceride level ≥150 mg/dL; and low high-density lipoprotein cholesterol (<40 mg/dL for men or <50 mg/dL for women) [
The sample size was calculated using a sample size calculation software program (G*Power version 3.1.9.2 for Windows), with an effect size of 0.484, statistical power of .80, and statistical level of significance of .05. The effect size was calculated from previous studies [
Exercise training was conducted at Kosin University Gospel Hospital. Each participant was instructed to immediately inform the study supervisor if he or she experienced any unusual symptoms during exercise training and to consult a physician if needed. Subjects were excluded from the final analysis if they did not perform more than 80% of the exercise sessions.
All subjects were randomly stratified into either an EXG group or a treadmill exercise (TE) group. Subjects underwent 2 weeks of adaptation and then carried out 12 weeks of exercise training for 60 min per day, 3 days per week, at 60% to 80% of their heart rate reserve (HRR). Each exercise session consisted of 10 min of warm-up, 40 min of main exercise, and 10 min of cooldown.
The EXG group performed exercise using the Exerheart equipment (D&J Humancare) that is composed of a running and jumping mat (730 width × 730 depth × 130 height) and a tablet personal computer placed on a stand (which could be adjusted to any height between 70 and 155 cm;
For both the EXG and TE groups, all subjects’ heart rates (HRs) during exercise were monitored using HR monitors (Polar RS400sd) to confirm that the value was within the target HR range. The Karvonen formula [
(A) The exergaming group performed exercise using Exerheart devices with permission from D&J Humancare, who is the copyright holder of Exerheart. (B) Features of the video game "Alchemist's Treasure.".
To assess executive function, a computer-based version of the Stroop task was administered using the Telescan software (LAXTHA Inc). During the task, subjects were presented with a color word appearing in the same color on congruent trials (eg,
Subjects performed the Stroop task twice, before and after exercise training. Subjects sat 1 m from the screen and when the color words appeared on the screen, they clicked the left keyboard for the congruent test and the right keyboard for the incongruent test. Subjects were instructed to respond as quickly and accurately as possible. The rate of measurement targeted for 50%. Each color word (vertical viewing angle: 2 degrees) was presented for 200 ms and a response was accepted within 1500 ms. The interstimulus interval varied randomly between 1500 and 2500 ms.
EEG activity was recorded during the modified Stroop task by using a computerized polygraph system (type A: a total of 31 channels Poly G-As, LAXTHA). Silver chloride electrodes (LAXTHA) were placed on the frontal (Fz), central (Cz), and parietal (Pz) cortex areas, according to the international 10-20 system. Midline locations were referenced to link earlobe electrodes. Horizontal and vertical electrooculograms were monitored by electrodes placed above and below the left eye and at the outer canthus of both eyes, respectively. The impedance of all electrodes was maintained below 10 kΩ. The bandpass filter of the amplifier was 0.1 to 100 Hz, the sampling rate was 1000 Hz, and a notch filter was established at 60 Hz.
The N200 component was defined as the largest positive peak occurring between 200 and 350 ms poststimulus, whereas the P300 component was defined as the largest positive peak occurring between 300 and 600 ms poststimulus [
Owing to the small sample size of this study, we used nonparametric statistics for data analysis. We used the Wilcoxon signed rank test to examine the changes of each dependent variable after the intervention within each group. The Mann-Whitney U test was employed to compare the delta values between training groups (Δ‐EXG group vs Δ‐TE group). The effect size of partial eta squared (η2) was reported for significant effects, where the alpha level for all of the tests was set at .05. Data were expressed as mean (SD). All statistical tests were processed using the Statistical Package for the Social Sciences version 24 software program (IBM Corp).
Demographic and physical characteristics for all subjects are provided in
The changes in congruent RT after 12 weeks of exercise training were not significantly different between the EXG and TE groups (
Baseline characteristics of study participants.
Factor | Group | ||
Exergaming (n=11), mean (SD) | Treadmill exercise (n=11), mean (SD) | ||
Age (years) | 64 (10) | 60 (7) | .30 |
Height (cm) | 154.24 (5.73) | 161.66 (7.1) | .01 |
Weight (kg) | 69.38 (10.54) | 71.47 (11.62) | .66 |
Body mass index (kg/m2) | 29.07 (3.3) | 27.31 (3.52) | .24 |
Waist circumference (cm) | 97.36 (10.95) | 93.6 (8.78) | .40 |
Glucose (mg/dl) | 123.55 (25.68) | 112.36 (29.37) | .35 |
High-density lipoprotein cholesterol (mmol/L) | 46.32 (8.91) | 50.59 (10.52) | .32 |
Low‐density lipoprotein cholesterol (mmol/L) | 66.19 (22.8) | 78.38 (19.52) | .19 |
Total cholesterol (mmol/L) | 134.81 (25.52) | 146.67 (12.04) | .18 |
Triglycerides (mmol/L) | 136.82 (78.88) | 145.73 (142.74) | .86 |
Systolic blood pressure (mmHg) | 127.09 (16.86) | 128.09 (17.39) | .89 |
Diastolic blood pressure (mmHg) | 75.55 (9.43) | 77.73 (11.99) | .64 |
Comparison of Stroop task congruent and incongruent reaction times of the exergame group and treadmill exercise group.
Effects, group | Pre, mean (SD) | Post, mean (SD) | Wilcoxon signed rank testa, |
Chi-square value | Mann-Whitney U testb, |
|
EXGc group | 1265.91 (383.15) | 1012.09 (221.64) | .01 | 0.053 | —d | |
TEe group | 1124.18 (161.21) | 957.82 (138.05) | .01 | — | — | |
EXG group | 1299.09 (367.48) | 984.73 (204.81) | .01 | 0.008 | — | |
TE group | 1171.36 (163.26) | 974.55 (120.97) | .01 | — | — |
aComparison of pre versus post within group.
bComparison of the delta values between EXG and TE group.
cEXG: exergaming.
dNot applicable.
eTE: treadmill exercise.
Mean reaction time during the Stroop task in the exergaming and treadmill exercise groups before and after the exercise intervention. (A) Congruent; (B) incongruent. EXG: exergaming; TEG: treadmill exercise group; ms: milliseconds. **Significant difference at P<.01 (Wilcoxon signed-rank test).
According to the results in
The changes in incongruent N200 amplitude for Fz, Cz, and Pz after 12 weeks of exercise training were not significantly different between the EXG and TE groups (
Comparison of Stroop task congruent and incongruent N200/P300 amplitudes of the exergame group and treadmill exercise group.
Components, effects, and group | Pre, mean (SD) | Post, mean (SD) | Wilcoxon signed rank testa, |
Mann-Whitney U testc, |
||||
EXGe group | −1.3 (1.95) | −4.1 (3.02) | .09 | 0.138 | .09 | |||
TEf group | −0.98 (3.14) | −0.41 (3.82) | .33 | —g | — | |||
EXG group | −1.59 (2.54) | −5.13 (2.94) | .03 | 0.291 | .01 | |||
TE group | −1.61 (3.89) | −0.97 (4.59) | .42 | — | — | |||
EXG group | −1.58 (1.89) | −4.06 (2.89) | .06 | 0.207 | .03 | |||
TE group | −1.32 (3.62) | −0.89 (3.99) | .53 | — | — | |||
EXG group | −2.85 (2.3) | −2.78 (3.02) | .48 | 0.041 | .37 | |||
TE group | −1.37 (3.3) | −0.73 (3.18) | .42 | — | — | |||
EXG group | −3.23 (2.69) | −3.93 (2.92) | .29 | 0.099 | .15 | |||
TE group | −1.9 (3.82) | −1.1 (3.65) | .21 | — | — | |||
EXG group | −2.86 (2.45) | −3.07 (2.62) | .72 | 0.008 | .70 | |||
TE group | −1.4 (3.66) | −1.01 (3.52) | .48 | — | — | |||
EXG group | 2.3 (1.94) | 7.12 (5.73) | .01 | 0.008 | .70 | |||
TE group | 3.21 (1.95) | 4.82 (3.78) | .01 | — | — | |||
EXG group | 1.92 (1.63) | 6.49 (5.28) | .01 | 0.006 | .75 | |||
TE group | 2.36 (0.93) | 5.08 (3.03) | .01 | — | — | |||
EXG group | 1.44 (1.69) | 5.2 (5.88) | .01 | 0.099 | .15 | |||
TE group | 1.74 (1.26) | 4.87 (3.64) | .33 | — | — | |||
EXG group | 2.26 (3.14) | 4.48 (3.27) | .09 | 0.018 | .56 | |||
TE group | 1.93 (2.26) | 3.85 (3.04) | .01 | — | — | |||
EXG group | 2.03 (2.8) | 4.38 (2.81) | .02 | 0.002 | .85 | |||
TE group | 1.59 (1.63) | 3.74 (2.99) | .02 | — | — | |||
EXG group | 1.58 (2.44) | 3.2 (2.73) | .02 | 0.000 | .95 | |||
TE group | 1.05 (0.92) | 3.33 (2.59) | .03 | — | — |
aComparison of pre versus post within group.
b
cComparison of the delta values between EXG and TE group.
dFz: frontal cortex.
eEXG: exergame.
fTE: treadmill exercise.
gNot applicable.
hCz: central cortex.
iPz: parietal cortex.
N200 and P300 amplitudes (mean [SE]) on 3 electrodes during the Stroop task in the exergaming and treadmill exercise groups before and after 12 weeks of exercise training. (A) Congruent N200 amplitudes; (B) incongruent N200 amplitudes; (C) congruent P300 amplitudes; (D) incongruent P300 amplitudes. Fz: frontal cortex; Cz: central cortex; Pz: parietal cortex; EXG: exergaming group; TEG: treadmill exercise group.
There were no significant differences in the changes in the incongruent P300 amplitude for Fz, Cz, and Pz between the EXG and TE groups after 12 weeks of exercise training (
Average event-related potential waveforms of electrodes for mean N200 and P300 amplitudes during the Stroop task in the exergaming and treadmill exercise groups before and after 12 weeks of the exercise training. (A) Congruent; (B) incongruent. Fz: frontal cortex; Cz: central cortex; Pz: parietal cortex; EXG: exergaming group; TEG: treadmill exercise group; ms: milliseconds.
This study was the first to investigate the benefits of EXG in comparison with normal exercise on the behavioral performance and executive function of patients with MetS. We found that 12 weeks of both EXG and TE training similarly and effectively improved behavioral performance and congruent and incongruent memory-related neural processing. However, only EXG training improved congruent selective attention, whereas neither EXG nor TE training affected incongruent selective attention. These results suggest similar overall effects for EXG and normal exercise on behavioral performance and executive function in patients with MetS but that EXG could be more effective than normal exercise for congruent selective attention.
This study showed that both 12 weeks of EXG and TE training effectively improved RT in MetS patients, and these changes were not different between the 2 training protocols. These results suggest that both EXG and normal exercise are able to improve behavioral performance, but EXG does not have more beneficial effects compared with normal exercise. In our previous study, we examined the performance of control tasks using a simple acute aerobic exercise and complex exercise [
In this study, the congruent and incongruent P300 amplitudes were increased after 12 weeks of both EXG and TE training, with no difference seen between the 2 groups. These results indicate that both EXG and normal exercise improve memory-related neural processing, but the beneficial effects of EXG are more significant than normal exercise. In other words, participation in exercise, regardless of the exercise modality, induces an increase in working memory in executive function. However, our previous study showed that P300 amplitude increased during a control task following futsal relative to seated rest or TE, indicating that complex control of the brain stimulates the executive control network of the cortex [
We found that neither EXG nor TE training affected the incongruent N200 amplitude. However, the consistent N200 amplitude was increased by EXG training. These findings suggest that, although neither EXG nor normal exercise affected incongruent selective attention, EXG improved congruent selective attention, which suggested that EXG has a more beneficial effect on congruent selective attention compared with normal exercise. The results of many studies on the relationship between exercise and the N200 amplitude indicate that exercise has no significant effect on the N200 amplitude [
Recent studies suggest that combining motor and cognitive demands during exercising can improve cognitive function more so than training these domains separately [
Our study provides evidence that EXG improves RT and incongruent memory-related neural processing in MetS patients as much as normal aerobic exercise does. In addition, EXG improves congruent selective attention, which was not changed by normal aerobic exercise. Therefore, EXG could provide an innovative way to enjoy aerobic exercise compared with repetitive, conventional exercises.
Although this study found significant results, there were some limitations: (1) The sample size in this study was relatively small (2) The age range was relatively large at 50 to 80 years. Considering that, with age, response time and brain activity become slower, we cannot rule out the possibility that age will affect the performance of executive function. However, the mean age was similar in both groups, so this possibility might be low in this study; (3) Finally, the intensity of Exerheart use while playing the
The results of this study suggest that EXG enhances brain responses to concentration and judgment, resulting in increased behavioral response among MetS patients comparable with the impact of normal aerobic exercise. Furthermore, the unique advantage of EXG is that it improves selective attention among cognitive functions, unlike normal aerobic exercise. Therefore, EXG could be recommended to some patients who need to improve executive function as well as physical fitness.
Participants played the video game with Exerheart.
CONSORT-eHEALTH checklist (V 1.6.1).
anterior cingulate cortex
central cortex
electroencephalographic
event-related potential
exergaming
frontal cortex
heart rate
heart rate reserve
metabolic syndrome
milliseconds.
parietal cortex
reaction time
treadmill exercise
treadmill exercise group
The authors would like to thank the study participants for their time and effort given while participating in this study. The authors declare that the results of this study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation.
None declared.